Provider Demographics
NPI:1578664314
Name:KRAGER, KIM B (OD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:B
Last Name:KRAGER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:M
Other - Last Name:BRIGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1025 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2403
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:1025 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-2403
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008509152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008509Medicaid